218.3 🩺 內科專科考前版

218.3.0.1 1⃣ When to Start ART in OI Setting

  • Most OIs: within 2 weeks of OI treatment start
  • Cryptococcal meningitis: delay 4-6 weeks (COAT trial — high IRIS mortality if early)
  • TB: depends on CD4
    • CD4 < 50: within 2 weeks
    • CD4 50-200: within 2-8 weeks
    • CD4 > 200: within 8-12 weeks
  • CNS TB: delay 4-8 weeks (IRIS risk)
  • CMV retinitis: start ART promptly with treatment

218.3.0.2 2⃣ COAT Trial (Cryptococcal ART Timing)

  • Earlier ART (within 2 wk) → high mortality in CrAg+ patients
  • Delayed ART (4-6 wk) → better survival
  • Standard now: delay 4-6 weeks
  • Especially relevant for low- and middle-income countries

218.3.0.3 3⃣ Steroid in OIs

OI Steroid Indication
PJP A-a > 35 or PaO2 < 70 — reduce mortality
Toxoplasmosis Mass effect / edema
Cryptococcal meningitis Not routine; IRIS severe; CSF pressure management priority
TB meningitis All TBM (reduces mortality)
PML-IRIS Severe inflammation
Cardiac tamponade pericardial TB All effusions

218.3.0.4 4⃣ TMP-SMX Intolerance

  • Allergic rash (10-15% HIV+)
  • Marrow suppression
  • Hyperkalemia, AKI
  • Alternative: dapsone (G6PD screen), atovaquone, pentamidine inhaled
  • Desensitization protocol if previous reaction

218.3.0.5 5⃣ Pediatric HIV + OIs

  • Same CD4-based prophylaxis (using % rather than absolute count)
  • Maternal PJP prophylaxis during pregnancy
  • Infants 4-6 wk post-delivery
  • TMP-SMX standard
  • BCG vaccination decisions (avoid in HIV-exposed infant if not yet treated)

218.3.0.6 6⃣ ICI (Immune Checkpoint Inhibitor) in HIV

  • ART + ICI for cancer treatment
  • Generally well-tolerated
  • ICI may have impact on HIV reservoir (research ongoing)
  • IRIS-like immune-mediated adverse events

218.3.0.7 7⃣ 健保 / Taiwan

  • 健保 OI prophylaxis (TMP-SMX, fluconazole, valganciclovir, etc.)
  • 健保 ART covered universally
  • HIV + OI hospital admission protocols
  • 盧醫垫 hint: 老 HIV+ 病人 — comprehensive OI prevention + vaccines + ART optimization; new HIV diagnosis CD4 < 200 → admission to start ART + OI prophylaxis

218.3.0.8 8⃣ Coccidioidomycosis Lifelong Prophylaxis

  • HIV + endemic SW USA exposure
  • CD4 < 250 → fluconazole 400 mg/d
  • Possible lifelong (high relapse rate)
  • Risk reduction with masks + dust precautions

218.3.0.9 9⃣ Future OI Management

  • Pre-emptive screening (CrAg in low-income with widespread CD4)
  • Earlier ART + better adherence reduces OIs
  • Vaccines: nirsevimab (RSV), Shingrix (HZ), pneumococcal, COVID + flu annual
  • New antifungals: rezafungin (echinocandin long-acting)

218.3.0.10 10. ART Initiation Pearls

  • All HIV+ should be on ART regardless of CD4
  • Rapid start within 7 days of diagnosis (or same day)
  • Even OI present (most): start ART + treat OI
  • Cryptococcal exception (delay 4-6 wk)